The use of cocaine causes numerous cardiovascular and pulmonary side effects. In this context, the occurrence of a pneumomediastinum represents a specific complication, often misunderstood by primary care physicians. We describe here on case of patient who suffered from subcutaneous emphysema and pneumomediastinum after smoking "crack". We emphasize the importance of always keeping in mind the possibility of illicit substance use in such cases, especially among young and healthy patients. A short observation period with outpatient follow-up is appropriate in the majority of patients. Invasive procedures have a low yield and should be based on a high degree of clinical suspicion for esophageal rupture or bronchial tree laceration.